Mod VI: Pediatric & Neonatal Anesthesia Emergencies

Question 1

_{Pediatric & Neonatal Anesthesia Emergencies}

Pediatric Airway obstruction/emergencies

Answer 1

Epiglottitis

Laryngotracheobronchitis or “croup”

Foreign body aspiration

Question 2

_{Pediatric & Neonatal Anesthesia Emergencies}

Developmental anomalies

Answer 2

Choanal atresia

Congenital diaphragmatic hernia

Bronchopulmonary dysplasia

Meconium aspiration syndrome

Question 3

_{Pediatric & Neonatal Anesthesia Emergencies}

Common pediatric congenital intra-abdominal malformations

Answer 3

Esophageal atresia and Tracheal Esophageal Fistula

Omphalocele and gastroschisis

Pyloric stenosis

Necrotizing enterocolitis

Intestinal obstruction

Question 4

_{Pediatric Airway Emergencies}

Inflammation of the epiglottis—the flap at the base of the tongue that keeps food from going into the trachea (windpipe)

Answer 4

Epiglottitis

This is a Life threatening airway emergency!!!

Question 5

_{Pediatric Airway Emergencies - Epiglottitis}

Etiology of Epiglottitis:

Answer 5

Bacterial infection (Haemophilus influenza type B)

Epiglottitis is rare vaccination offers protection

Question 6

_{Pediatric Airway Emergencies - Epiglottitis}

Why is inflammation a/w Epiglottitis considered “Supraglottitis”?

Answer 6

Tissue from vallecula→ arytenoids are affected

Question 7

_{Pediatric Airway Emergencies - Epiglottitis}

Epiglottitis affect patients that are usually how old?

Answer 7

2-7 y/o

Question 8

_{Pediatric Airway Emergencies - Epiglottitis}

What’s the Clinical presentation of Epiglottitis?

Answer 8

Sudden onset high fever (>39 C)

Dysphagia

Drooling

Thick-muffled voice

Sitting with head extended leaning forward (Tripod Position)

Severe obstruction: stridor, retraction, labored breathing, cyanosis

Question 9

_{Pediatric Airway Emergencies - Epiglottitis}

What’s the hallmark clinical sign of Epiglottitis?

Answer 9

Tripod Position

Sitting with head extended leaning forward

Question 10

_{Pediatric Airway Emergencies - Epiglottitis}

Normal vs inflamamed epiglottis

Answer 10

See picture

Question 11

_{Pediatric Airway Emergencies - Epiglottitis}

Initial management of Epiglottitis

Answer 11

Administer 100% O2/ face mask

^—

KEEP CHILD CALM!!!!

^{Allow parental presence}

^{Avoid blood draws, IV starts, excessive manipulation before airway is secured}

Do not place the child supine

^—

Stable→ obtain lateral x-rays of soft tissue of neck

^{“thumb” sign}

Epiglottitis confirmed or Airway compromised→ directly to OR

^{OR/ENT/Anesthesia must be notified and prepared completely}

^{Have appropriate sized ET, blades, OA, pulse oximeter, Ambu bag/mask, portable suction& succinylcholine/atropine IM available during transport}

^{TRANSPORT ONLY WITH ANESTHESIA /ENT SURGEON CAPABLE OF EMERGENCY AIRWAY MANAGEMENT}

Question 12

_{Pediatric Airway Emergencies - Epiglottitis}

Stable→ obtain lateral x-rays of soft tissue of neck. What sign are you looking for?

Answer 12

“Thumb” sign

Outpouching of soft tissue towards the spinal cord

Should not be there normally on a healthy person

Indicates excessive swelling around the epiglottis

Question 13

_{Pediatric Airway Emergencies - Epiglottitis}

T/F: AT NO TIME SHOULD DIRECT VISUALIZATION OF EPIGLOTTIS BE ATTEMPTED IN AN UNANESTHETIZED PATIENT!!!!!!

Answer 13

TRUE

_{It’s very important to keep them calm and not hyperventilating}

_{Make sure they are anesthetized before any direct airway visualization}

_{Not following these guidelines could lead to total airway obstruction}

Question 14

_{Pediatric Airway Emergencies - Epiglottitis}

Another view of the “Thumb” sign

Answer 14

See picture

Question 15

_{Pediatric Airway Emergencies - Epiglottitis}

Anesthesia considerations/management w/ Epiglottitis

Answer 15

Minimize manipulation of child

Remain in upright position

Precordial and pulse oximeter monitoring adequate

Allow parental presence until LOC of child

Gradual inhalation induction with sevoflurane & 100% O2 maintaining spontaneous ventilation

^{Avoid PPV if possible}

Start IV with LOC/loss of lid reflex→ atropine if indicated

Tracheal intubation*

Question 16

_{Pediatric Airway Emergencies - Epiglottitis}

Tracheal intubation w/ Epiglottitis:

Answer 16

Deep inhalational anesthesia

O_ne size smaller ETT/Stylette_

Avoid muscle relaxants until airway established

LMA not useful!

^{All the swelling will still be south of the opening, and all of the obstruction will still be present => <u>Must use an ET tube</u>}

Tracheostomy/cricothyroidotomy with l_ife-threatening hypoxia_

Question 17

_{Pediatric Airway Emergencies - Epiglottitis}

If unable to identify vocal cords, what can you do to ID airflow location?

Answer 17

Have the pt spontaneously ventilate still

Look for gas bubbles coming out

If pt apneic at this point, you could do gentle pressure on the pt’s chest to try to elicit a bubble; this may allow identification of airflow location

Question 18

_{Pediatric Airway Emergencies - Epiglottitis}

Postoperative management of Epiglottitis:

Answer 18

Continue mechanical ventilation

^{<u>Sedation</u> appropriate at this time}

^{<u>Propofol</u>?? (consider “<strong>Propofol infusion syndrome</strong>”)}

IV Antibiotics

Tracheal extubation*

Question 19

_{Pediatric Airway Emergencies - Epiglottitis}

Which criteria must be met before Tracheal extubation following Epiglottitis?

Answer 19

Significant leak around ETT is present and

Visual inspection of larynx by flexible bronchoscope confirms reduction in swelling

Attempted usually 48-72 hrs later

Question 20

_{Pediatric Airway Emergencies}

The type of respiratory infection that is usually caused by a virus. The infection leads to swelling inside the trachea, which interferes with normal breathing and produces the classic symptoms of “barking” cough, stridor, and a hoarse voice is also known as:

Answer 20

Laryngotracheobronchitis or “Croup”

Question 21

_{Pediatric Airway Emergencies - Laryngotracheobronchitis: “Croup”}

Etiology of “Croup”:

Answer 21

Primarily viral

Question 22

_{Pediatric Airway Emergencies - Laryngotracheobronchitis: “Croup”}

“Subglottic” narrowing in “Croup” is d/t:

Answer 22

Inflammation of subglottic tracheal mucosa and the entire tracheal bronchial tree

Question 23

_{Pediatric Airway Emergencies - Laryngotracheobronchitis: “Croup”}

“Croup” is prevalent in which age group?

Answer 23

Occurs in children 6mos - 6y/o

Primarily seen < 3y/o

Question 24

_{Pediatric Airway Emergencies - Laryngotracheobronchitis: “Croup”}

Clinical presentation of “Croup”:

Answer 24

More insidious than epiglottitis

Viral prodrome (URI)

Low-grade fever

Hoarseness

Varying degree inspiratory stridor

“Barking” cough

Tachypnea, tachycardia, cyanosis (severe cases)

“Steeple” sign on x-ray examination

Question 25

_{Pediatric Airway Emergencies - Laryngotracheobronchitis: “Croup”}

Presentation of “Croup” on x-ray examination

Answer 25

Steeple” sign

Question 26

_{Pediatric Airway Emergencies - Laryngotracheobronchitis: “Croup”}

Presentation of “Steeple” sign

Answer 26

See picture

Question 27

_{Pediatric Airway Emergencies - Laryngotracheobronchitis: “Croup”}

Treatment of “Croup”

Answer 27

6% require hospitalization

Cool, humidified mist & O2 therapy (tent)

Racemic epinephrine (2.25%) by nebulizer

Steroids (controversial)

^{Current opinion: short courses beneficial}

Intubation for pulmonary toilet/suctioning if thick secretions present

^{Management of PICU/<u>extubation similar to epiglottis</u>}

^{Difference:<u> PPV with bag/mask may be beneficial</u>}

Question 28

_{Pediatric Airway Emergencies - Epiglottitis}

Organism - Age - Onset:

Answer 28

See picture

Question 29

_{Pediatric Airway Emergencies - Laryngotracheobronchitis: “Croup”}

Organism - Age - Onset:

Answer 29

See picture

Question 30

_{Pediatric Airway Emergencies - Epiglottitis}

Region affected - Lateral Neck X-ray - Clinical presentation & Treatment

Answer 30

See picture

Question 31

_{Pediatric Airway Emergencies - Laryngotracheobronchitis: “Croup”}

Region affected - Lateral Neck X-ray - Clinical presentation & Treatment

Answer 31

See picture

Question 32

_{Pediatric Airway Emergencies}

Major cause of morbidity/mortality

Answer 32

Foreign Body Aspiration

Most deaths: at time of aspiration

Mortality rate = 0% if child arrives to ER alive

Question 33

_{Pediatric Airway Emergencies - Foreign Body Aspiration}

Foreign Body Aspiration mostly occurs at what age?

Answer 33

Between 7mos & 4 y/o

Question 34

_{Pediatric Airway Emergencies - Foreign Body Aspiration}

Most common site of occurence of Foreign Body Aspiration

Answer 34

Proximal airway (75%)

Right main-stem bronchus

Question 35

_{Pediatric Airway Emergencies - Foreign Body Aspiration}

Most common item responsible for Foreign Body Aspiration

Answer 35

Food particles

Question 36

_{Pediatric Airway Emergencies - Foreign Body Aspiration}

Clinical presentation of Foreign Body Aspiration

Answer 36

Witnessed

^{Choking, coughing, cyanosis}

Unwitnessed Suspected (ER)

^{↓ Breath sounds - Tachypnea - Refractory wheezing - Fever}

Question 37

_{Pediatric Airway Emergencies - Foreign Body Aspiration}

What will Radiological exams of Foreign Body Aspiration reveal?

Answer 37

90% are radiolucent

Postobstruction air trapping/emphysema

Unilateral infiltrates/atelectasis

Pneumonia

Question 38

_{Pediatric Airway Emergencies - Foreign Body Aspiration}

Treatment of Foreign Body Aspiration

Answer 38

Bronchoscopy - Laryngoscopy

Emergency situation requiring removal in the OR only

Question 39

_{Pediatric Airway Emergencies - Foreign Body Aspiration}

Picture showing X-ray presentation of Foreign Body Aspiration

Answer 39

_{See picture}

Question 40

_{Anesthetic considerations/management of Foreign Body Aspiration}

T/F: GIVE SEDATION/PREMED BEFORE REMOVAL OF FB

Answer 40

FALSE

NO SEDATION/PREMED BEFORE REMOVAL OF FB

Question 41

_{Anesthetic considerations/management of Foreign Body Aspiration}

Spontaneous vs. Controlled ventilation

Answer 41

…

Question 42

_{Anesthetic considerations/management of Foreign Body Aspiration}

Spontaneous Ventilation considerations w/ Foreign Body Aspiration include:

Answer 42

Inhalation induction (if NP0) with Sevo/100 % O2

SV maintained

VC sprayed with topical lidocaine (2% school age, 1% small infant)

^{Must obtain adequate depth of anesthesia to prevent coughing/bucking}

Intubate and suction stomach

Give airway to surgeon: replaces ET with ventilating bronchoscope

^{Gas/O2 provided by side arm of bronchoscope}

Question 43

_{Anesthetic considerations/management of Foreign Body Aspiration}

Advantages of Spontaneous Ventilation

Answer 43

Better airflow distribution

Uninterrupted ventilation

Assess ventilatory mechanics after removal FB

Question 44

_{Anesthetic considerations/management of Foreign Body Aspiration}

Disadvantages of Spontaneous Ventilation

Answer 44

Risk of patient movement

Prolonged emergence

Question 45

_{Anesthetic considerations/management of Foreign Body Aspiration}

Controlled ventilation considerations w/ Foreign Body Aspiration include:

Answer 45

RSI with OET intubation

Maintenance: Propofol, remifentanil gtt, short-acting muscle relaxant

Ventilation performed in concert with surgeon

Apneic ventilation: Periods of hyperventilation interspersed with brief periods of bronchoscopy

Jet ventilation: RR normal, duration of breath guided by chest expansion/pulse oximetry, allow for adequate exhalation essential

Question 46

_{Anesthetic considerations/management of Foreign Body Aspiration}

Advantages of Controlled ventilation

Answer 46

Rapid control of airway

No patient movement

Decreased anesthetic requirements

Question 47

_{Anesthetic considerations/management of Foreign Body Aspiration}

Disadvantages of Controlled ventilation

Answer 47

Ventilation interrupted

Depth of anesthesia unreliable (if using gases)

Risk of FB dislodgement distally

Barotrauma with hyperinflation

Question 48

_{Anesthetic considerations/management of Foreign Body Aspiration}

How and why would you convert a Partial obstruction into a complete obstruction during bronchoscopy

Answer 48

Push object into mainstem bronchus to allow life saving ventilation of opposite lung